APPs key to pandemic planning

Advanced practice providers (APPs) shifted roles in preparation for a COVID-19 surge.

At our urban, academic medical center, hospitalists' expertise in emergency preparedness and advanced practice providers' (APPs) skill in adapting to rapidly changing situations were combined to effectively respond to the COVID-19 pandemic.

Dr Vanderzwan
Dr. Vanderzwan

Our APP service, which includes both nurse practitioners and physician assistants (PAs), typically supports 10 physician lines of hospital medicine service five days a week. To prepare for COVID-19 staffing needs, the hospital medicine division instituted plans to increase the capacity of medical beds by 300 and lines of service from 10 to 30.

Hospital medicine leadership put out a call for APP volunteers from medicine subspecialties and surgical departments. In conjunction with leads in the medical and surgical departments, the director of professional practice for APPs and the lead hospital medicine PA designated three emergency staffing lines: emergency department, ICU, and hospital medicine. Instead of the usual seven APPs on the hospital medicine service per weekday, five were assigned in an effort to extend coverage over the weekends. Additionally, six to seven APPs from the other services were paired with the five hospital medicine APPs for training.

Ms Walters
Ms. Walters

The first volunteers were other lead APPs from other medical subspecialties and surgery. In total, approximately 40 APP volunteers from low-census medicine subspecialty and surgical areas had the ability to float to the hospital medicine department. APPs needed to have inpatient privileges, and experience and preference were given to those with medicine experience. Within the first week after the plans were made, 30 of these surge staffers were onboarded. Their assigned duties ranged from assisting with coordination of patient care and communication with family and patients to the full scope of their practice. Surge APPs were assigned one on one with an attending physician, sharing a set of 10 patients.

Two care models evolved. Either the APP and attending physician would round together on all of the patients and divide tasks, or the APP would take three to four patients to staff independently and the physician would attest to the APP's note. Only one of the two clinicians saw each patient face-to-face each day, and some patients were seen via telemedicine. A no-visitor policy created a need for added communication with patients, families, primary care clinicians, and consultants that the surge staff facilitated with modalities including video and telephone. Regularly scheduled interdisciplinary rounds and newly implemented COVID-19 rounds (with hospital medicine, infectious diseases, ICU, and anesthesia clinicians) were held each day. The hospital also developed a plan to bring in outpatient primary care doctors to help with pandemic patient volume. APP volunteers were also key to this strategy, as they were paired with outpatient physicians to share their experience providing direct care in the hospital.

This care model was in use for about six weeks. With the increased staffing, we were prepared for up to 300 COVID admissions at a time. The hospital only admitted half that number; however, the surge caused by COVID admissions lasted longer than expected. It took about six weeks until we saw significant decline in census. The flexibility of APPs was highlighted during this time as they stepped in and found ways to help during this unprecedented pandemic. This experience shed light on the importance of this kind of cross training. A cross-training model should not only be in place for unusual circumstances, but also to support resiliency, engagement, and learning by APPs. We were lucky that early social distancing and quarantining in our state allowed to us avoid the overcrowding experienced by the other metropolitan hospital systems whose models we followed.

As COVID-19 cases declined and medical subspecialty clinical visits and elective surgeries resumed, the institution shifted away from surge APP usage. However, the plan is ready should a second COVID-19 surge erupt. Our experience shows how APPs were ready to step into a division they were unfamiliar with and begin working with physicians they did not know during a pandemic laden with stress, anxiety, and uncertainty. This is neither the first nor the last surge in patient volume we are likely to see, and we hope that this APP model will be useful to other hospitals struggling with COVID-19 staffing resources.